BPD and Employment

November 2, 2008

The American Psychiatric Association (APA) estimates that roughly 2% of the general population is diagnosable with borderline personality disorder (BPD). This conservative estimate suggests that at least 84,000 people in the Tampa Bay area alone are diagnosable with BPD. Many of these individuals are successfully employed; many are not. This article will briefly explore some of the impediments to employment that may be experienced by individuals with BPD, accommodations that could assist with successful employment, and an overview of Florida’s Division of Vocational Rehabilitation, a government program that can assist some individuals with BPD and other mental conditions with stable, appropriate employment.

According to the APA’s Diagnostic & Statistical Manual of Mental Disorders (DSM-IVTR), the essential features of BPD include:

(1) A pervasive pattern of instability of interpersonal relationships, self-image, and affects. The word pervasive literally means “spread throughout.” In other words, this instability seems to affect multiple areas of the individual’s life and is a relatively ingrained experience for the individual. People with BPD may strongly dislike aspects of themselves, and emotional regulation (the ability to modify emotional experiences or behaviors that are driven by emotion) may present a challenge. People with BPD may be overly sensitive to the actions and behaviors of others or to circumstances in their environment. They may experience strong fears of abandonment, conclude that others are abandoning them, and believe that this abandonment somehow means that they are “bad.” The abandonment may be related to a fear or intolerance of being alone, and people with BPD may have a strong preference to have others around them. People with BPD may experience rigid, dichotomous thinking, in which they view things or people as being excessively bad or good, right or wrong. This may lead to behaviors or statements that the average person would consider to be an over-reaction.

(2) Marked impulsivity that begins by before or during early adulthood. Impulsivity refers to a tendency to act based on an impulse, such as a feeling, rather than on thought. One way to think of this is to picture the mind as 3 different parts: the feeling mind (focuses on feelings, emotions, and impulses), the thinking mind (focuses on thoughts, reason, and logic), and the wise mind (focuses on a balance between both thoughts and feelings). People with BPD may be more attuned to the feeling mind then the wise mind. When they feel abandoned or alone, they may participate in impulsive behaviors, such as self-mutilation, suicidal threats or behaviors, sexually impulsive behavior, or substance abuse in an effort to address those uncomfortable feelings. Some experts conceptualize this impulsivity as a way of testing out or acting out beliefs that one is unlovable.

BPD and Employment

From a vocational rehabilitation perspective, some people with BPD may experience some of the following impediments to employment:

• Difficulty relating appropriately with co-workers and supervisors.
• Inappropriate response to work/social situations.
• Difficulty concentrating on work activities

If a person’s borderline traits are contributing to depression, then the individual may also experience:
• Absenteeism or tardiness from work
• Need for increased time and attention to learn work skills
• Difficulty staying on task
• Limited stamina to perform work duties

When combined with other co-occurring disorders, such as substance dependence, multiple other impediments can present themselves.

I’ll provide an example of how a person’s borderline tendencies may produce the three impediments listed above. Shelly, who has been diagnosed with BPD, is an accountant at a busy firm. She informs her supervisor, Rodney, that her office is too cold. Instead of changing the thermostat, Rodney says he would like to poll the other employees to see if they are also cold, so that he can ensure the most comfortable temperature for everybody. Shelly interprets the supervisor’s response as being unsupportive rather than egalitarian, and she accuses him verbally of not caring about her work conditions.

These types of encounters repeat themselves frequently, and Rodney begins to feel exhausted and frustrated with addressing the Shelly’s complaints about lack of support. He begins to view Shelly as excessively combative and selfish. Believing that she lacks commitment to the firm and the capacity to be a good team player, Rodney passes Shelly up for a promotion, despite that she was the most experienced member of the team and is very productive with her work. Shelly, in turn, views Rodney’s decision as further evidence that he is a “bad” supervisor and becomes convinced that he wants to terminate her. She finds it difficult to focus on her work because she is emotionally and cognitively distracted with ruminating thoughts of how she has been victimized and mistreated, and she begins to fear for her economic security. She also starts to view herself as being an overall inferior employee, even though her work is satisfactory.

Shelly begins to seek support from her co-workers and engages in lengthy conversations with them during the end of a financial quarter, when the workload is heavy and many employees are working overtime. Her co-workers begin to feel frustrated, discouraged, and distressed by her time-absorbing complaints about her work environment and supervisor. Office gossip increases, providing further dissension among co-workers and negatively impacting employee morale. Meanwhile, Shelly finds it more and more difficult to focus on her work activities and stay organized, leading to a decrease in her production.

Accommodations for Employees with BPD

Several accommodations can be provided by employers for individuals with BPD. Some of these accommodations are designed to support self-care, others to reduce work-related stress, and others to encourage positive interactions with co-workers and supervisors.

Examples of Job Accommodations for Employees With BPD
• Allow flexible work scheduling so that employees can attend counseling or psychiatric appointments.
• Allow use of supported employment or job coaches.
• Consider a program that allows employees to work from home on some days.
• Allow employees to play soft, quiet, relaxing music at their work spaces.
• Provide space enclosures or a private office.
• Offer appropriate praise and reinforcement for positive work interactions.
• Plan for blocks of uninterrupted work time.
• Use natural or full spectrum lighting.
• Encourage use of breaks and vacation hours.
• Rearrange larger job tasks into smaller tasks.
• Make daily “TO-DO” lists and check items off as they are completed
• Use several calendars to mark meetings and deadlines
• Use electronic organizers.
• Provide an Employee Assistance Program (EAP) and encourage use of the EAP.
• Provide sensitivity training to coworkers and supervisors
• Do not mandate that employees attend work related social functions
• Encourage all employees to move non-work related conversations out of work areas
• Provide weekly or monthly meetings with the employee to discuss workplace issues and productions levels
• Use active listening skills when an employee discussed challenges in the workplace. Provide assistance and support for problem-solving.
• Allow telephone calls or phone breaks during work hours to therapists and others for needed support.
• Provide written checklists and instructions.
• Develop clear, written office procedures and enforce them fairly and equitably.
• Establish written long-term and short-term goals.

Source: Job Accommodation Network, U.S. Dept. of Labor

For many employees with BPD, counseling may be an essential support for stable employment. Ideally, employees with BPD should be referred to therapists who have experience, training, expertise, and an interest in working with individuals with BPD. Therapists who have been trained in therapies empirically demonstrated to be effective for people with BPD, such as Dialectical Behavior Therapy (DBT), are ideal referral resources. Employees with BPD may be encouraged to use helpful self-talk at work, monitor their thoughts, question their perceptions internally, and recite adaptive self-statements, some of which could be put on a card or sticker and positioned in the employee’s workspace.

Vocational Rehabilitation: A Resource for Employment

The Division of Vocational Rehabilitation (VR) is a state agency under the Florida Dept. of Education. VR can assist eligible individuals with disabilities in preparing for, getting, keeping, or regaining suitable employment. Eligibility requirements include:
• The individual has a physical or mental impairment (e.g. BPD) that constitutes or results in an impediment to employment;
• The individual can benefit from VR services in terms of an employment outcome;
• The individual requires VR services in order to successfully obtain or maintain suitable employment.

Some individuals with BPD are appropriate for VR services for assistance in employment. Services are provided on an as-needed, individualized basis. Examples of VR services include:
• Counseling and guidance
• Vocational evaluation
• Assistance with training or education needed to work
• Placement (use of job coaches or placement specialists to secure employment)
• Assistance with prescription medications or psychotherapy
• Tools and supplies needed for work
• Transportation needed for work (e.g. bus passes)
• Assistance with identifying and implementing job accommodations
• Referral to appropriate community agencies.

Individuals interested in VR services are encouraged to contact a local VR office to inquire about orientation. An office listing can be obtained at www.rehabworks.org by clicking on the “Office Directory” link or by calling 1-800-451-4327.

—Aaron Norton, MA, CAP, CMHP

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